Why PCM Works for CHF

CHF management requires constant monitoring of symptoms, fluid balance, and medication regimens. Patients often need frequent medication titration, coordination with cardiology, and education on daily self-management. PCM allows practices to dedicate time to one condition without requiring the presence of multiple comorbidities, as is the case with Chronic Care Management (CCM).

Patient Selection Criteria

PCM for CHF should target:

• Patients with Stage C or D heart failure requiring intensive follow-up

• Those recently hospitalized or seen in the ED for CHF exacerbations

• Patients requiring frequent diuretic titration or medication changes

• Individuals using home monitoring tools such as daily weights or BP cuffs

• Patients at high risk of readmission due to non-adherence or fluid overload

PCM Codes for CHF

• 99426 – 30 minutes of clinical staff time/month under physician or QHP direction

• 99427 – Each additional 30 minutes of clinical staff time

• 99424 – 30 minutes of physician or QHP time/month (if payer recognized)

• 99425 – Each additional 30 minutes of physician/QHP time

Documentation must include:

• Focused CHF-specific care plan

• Time logs with staff attribution

• Evidence of non-face-to-face communication and coordination

Care Plan Requirements for CHF

A PCM care plan for CHF should include:

• Diagnosis and stage of CHF

• Medication list including diuretics, beta-blockers, ACE inhibitors/ARNIs

• Daily weight monitoring protocol

• Sodium and fluid restriction guidance

• Follow-up schedule with cardiology and primary care

• Education on symptom recognition (shortness of breath, edema, weight gain)

• Emergency instructions for acute exacerbations

Workflow Integration

1. Identify Eligible Patients: Use hospital discharge feeds or EHR reports for CHF admissions.

2. Enroll with Consent: Document verbal or written consent in the chart.

3. Care Plan Creation: Develop a CHF-specific plan, accessible to the patient and care team.

4. Monthly Outreach: Conduct 30+ minutes of staff-led follow-up, including medication reconciliation, symptom checks, and escalation to provider when needed.

5. Documentation & Billing: Record time, interventions, and staff attribution; bill PCM codes monthly.

Benefits of PCM for CHF

• Reduced Readmissions: Structured follow-up decreases 30-day hospitalizations.

• Medication Safety: Prevents adverse events by closely monitoring titrations.

• Patient Engagement: Empowers patients to track daily weights and symptoms.

• Revenue Capture: PCM creates sustainable reimbursement for focused condition management.

• Care Coordination: Aligns primary care and cardiology efforts for better outcomes.

Key Takeaways

• CHF is an ideal condition for PCM because it requires intensive, condition-specific management.

• PCM codes (99426–99427, 99424–99425) support billing for monthly follow-up and coordination.

• A focused CHF care plan is essential, covering medications, daily monitoring, lifestyle restrictions, and emergency protocols.

• PCM helps practices reduce readmissions, improve patient quality of life, and sustain program revenue.